AFCA Upholds Insurer’s Decision in Breast Cancer Claim Case
AFCA Upholds Insurer’s Decision in Breast Cancer Claim Case
The information on this website is general in nature and does not take into account your objectives, financial situation, or needs. Consider seeking personal advice from a licensed adviser before acting on any information.
A recent ruling by the Australian Financial Complaints Authority (AFCA) has affected a woman’s critical illness claims, as her diagnosis came within mere days of her policy's eligibility period drawing to an end.
The woman was diagnosed with cancer in her right breast on October 5 of last year, followed by the discovery of cancer in her left breast eight days later. She filed claims under her critical illness policy that she had obtained on July 17.
However, TAL Life, her insurance provider, rejected the claims based on the policy's three-month qualifying period for cancer coverage.
In its ruling, AFCA noted that the policy had provisions to potentially waive the qualifying period if the policyholder could prove they were insured either under a previous TAL policy or by another insurer for the same events, right before their new coverage commenced.
The claimant contended that she had cancer coverage through an insurance policy provided by her husband's employer. She presented a letter from the employer affirming that she was covered under a "life, accident, critical illness, and medical insurance" scheme from August 2020 until June last year. Additionally, she showed documentation indicating her husband’s policy did include critical illness coverage for spouses, encompassing cancer.
While AFCA accepted the availability of this cancer coverage, it was not convinced that she held such coverage "immediately before the current policy began." It also noted she had failed to disclose her previous insurance when applying for the new policy with TAL Life.
"There is no information before me about the extent of the critical illness cover the complainant had, if any, through her husband's employer’s insurance arrangements," AFCA’s ombudsman stated.
"Furthermore, it appears that any cover she might have had ceased about a month before the new policy started. I am not convinced there was 'continuity of cover' as suggested by the complainant."
The ombudsman expressed AFCA’s sympathy towards the claimant, especially given that the diagnoses occurred "very close to the end of the qualifying period." Nonetheless, he emphasized that there was no valid reason for the qualifying period to be dismissed.
"The qualifying period is reasonably short and its existence is not unjust. These terms are part of all insurance policies and they draw necessary boundaries. The enforcement of these terms is not inherently unfair," the ombudsman elaborated.
For a more detailed account of the ruling, refer to the original report by AFCA.
Please Note: We do not endorse any specific products or companies. Some content is sourced from third parties, including press releases, and may not be independently verified for accuracy or completeness.
Emergence Insurance has announced the acquisition of Blue Zebra's cyber insurance portfolio, marking a significant expansion of its cyber risk offerings in the Australian market. This move is set to bolster Emergence's capabilities in providing comprehensive cyber insurance solutions to businesses across the country. - read more
In response to the increasing threat of bushfires in urban fringe areas, a state government has commenced trials of new mitigation measures designed to enhance community safety. These initiatives aim to reduce the risk and impact of bushfires on residential communities situated near bushland. - read more
HESTA, a prominent superannuation fund in Australia, has unveiled a significant reduction in insurance fees, averaging 12% across all cover types. This initiative, effective from 1 July 2026, aims to provide more accessible and affordable insurance options for its members, including those in the trades sector. - read more
Suncorp, a leading Australian general insurer, has secured a substantial reinsurance agreement valued at up to AU$2.4 billion over five years. This strategic move has positively impacted the company's fiscal 2026 growth outlook, resulting in a notable 10% increase in share value. - read more
Zurich Financial Services has announced its agreement to acquire ClearView Wealth, a listed life insurer, for approximately AU$415 million. This acquisition is part of a broader trend of consolidation within the Australian insurance market, following similar moves by other major players in the industry. - read more
For tradespeople, protecting your tools and equipment is crucial. These are not just tools; they are the backbone of your business. Without them, you can't complete jobs, meet client expectations, or generate income. This includes your Vehicle. - read more
Trades insurance is a specialised type of coverage designed to protect individuals and businesses in the trades industry. This category includes a wide range of professionals such as electricians, plumbers, builders, and other manual workers who face unique risks in their day-to-day operations. - read more
Insurance is a critical component for tradespeople in Australia, providing financial protection against a range of risks that can significantly impact your livelihood. Adequate insurance coverage ensures that you are protected against potential liabilities, damages, and unforeseen circumstances that could otherwise lead to substantial financial losses. - read more
Insurance is a crucial safeguard for everyone, but for subcontractors, it's essential. In the world of trade professionals, the tools of the trade are more than just pieces of equipment; they are investments into one's livelihood. - read more
Knowledgebase
Umbrella Policy: An additional insurance policy that provides extra liability coverage beyond the limits of the insured's primary policies.
No comments yet. Be the first to share your thoughts.